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CDI: Just Tell Me What to Say

Standardized Queries Meet ICD-10

Published June 20, 2011 10:36 AM by Alice Zentner

Another area where clinical documentation improvement (CDI) and ICD-10 should be coming together now is that of standardized queries. Where are your queries in the transition to ICD-10? Best practice suggests that you should look at them now and update them sooner; rather than later!

Most hospitals already have a series of standard queries in commonly occurring diagnoses. These may include such areas as:

  • Heart Failure
  • Pneumonia
  • Diabetes
  • Surgical Debridement
  • Stroke
  • Sepsis vs. Bacteremia
  • COPD / Asthma
  • Anemia
  • Renal disease
  • Neurological conditions

These are some common examples, but certainly not all. The point is that standardized queries are already in place and with some diligence they can be used as a catalyst for better physician documentation under ICD-10. The process is fairly straight forward:

    1. Collect and review all existing queries
    2. For each query, identify what additional documentation will be needed to code correctly in ICD-10
    3. Assign staff to update the queries
    4. Slowly start using the new queries on current cases
    5. Use your physician champion to get physicians up to speed

By updating and using ICD-10 ready queries now, you'll bring physicians along slowly and minimize disruption at ICD-10 go-live. The updates should be written by a CDI specialist using the same criteria that went into the initial query. For example, do not lead the physician in a particular direction. Be general and let the physician give the appropriate documentation and let the diagnosis fall where it may.

Granted the issue of complication and co-morbidity (CC) and major complication and co-morbidity (MCC) is still an open item in ICD-10 and may require further changes to your queries. However, don't let this stop your progress. Keep your query updates going forward. After all CDI is an ongoing continuous process.

posted by Alice Zentner
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